Abstract and Introduction
Abstract
Introduction: Because applying a splint for a wound on a patient’s trunk or neck (including areas such as the shoulder, chest, buttock, axilla, and abdomen) is considerably difficult, grafted skin may not firmly affix at the wound site.
Objective: A study was conducted to compare negative pressure wound therapy (NPWT) to conventional bolster dressings in facilitating firm split-thickness skin graft (STSG) attachment and allowing relatively easy removal of exudates.
Materials and Methods: A randomized controlled trial was conducted among 57 patients with wounds on the trunk or the neck who received STSGs between January 2013 and December 2017. Prospective and retrospective data were used for analysis in this study. Patients who were pregnant, immunocompromised, or had severely infected wounds were excluded from the study. Due to discomfort, splints were not used. Patients were divided into 2 groups. Group 1 was provided a NPWT dressing; NPWT was applied continuously for 6 days between -75 mm Hg and -100 mm Hg with dressing changes at postoperative days 3 and 6. After postoperative day 6, antibiotic cream and a nonadherent foam dressing were used on the wounds. Group 2 was provided a conventional bolster dressing for the same time frame. The Mann-Whitney U test was used to compare the variables and outcomes between the 2 groups. Differences were considered statistically significant for P < .05.
Results: Among the 57 patients, 27 received NPWT and 30 received the bolster dressing. The size of the wounds in these patients ranged between 100 cm2 and 400 cm2. In group 1, the average survival score for the skin graft was more than 80 in all patients after postoperative day 7. In group 2, major graft loss occurred in 5 patients, requiring a second STSG. The average score of STSG survival on postoperative day 7 in group 2 was lower than that of group 1. The differences observed between the 2 groups were overall statistically significant (P < .01) based on the results of the Mann-Whitney U test.
Conclusions: Owing to the flexibility and elasticity afforded by the transparent adhesive film that is used in NPWT technique, patients were more mobile and felt little discomfort compared to conventional procedures. The negative pressure dressing increased the percentage of graft survival and may reduce need for a second STSG.
Introduction
A split-thickness skin graft (STSG) is commonly used for wound coverage owing to its ease of use, the ability to expand coverage via meshing procedures, and the better quality of scar healing than that obtained via secondary interventions.[1] However, STSGs on the trunk or the neck are associated with high rates of morbidity, which presents a significant problem for the patient and surgeon during the early postoperative period. The rate of STSG failure in total has been reported to be between 0% and 33%.[2]
The recipient area for the STSG must not be infected or excessively exudative; granulation tissue, if present, must be flat and not produce much exudate; and hemostasis must be ensured. Any collection of exudate or blood under the graft jeopardizes graft survival because it hinders adherence and penetration of newly formed capillaries Negative pressure dressing was applied for 6 days with the first negative pressure dressing being changed on postoperative day 3 and the second dressing on day 6. After postoperative day 6, antibiotic cream and nonadherent foam dressing were used on the wounds. Therefore, immobilization of the STSG is critical for fixation. In cases where STSG recipient areas are on the extremities, splints have been shown to be useful for preventing mechanical detachment;[3] however, this approach prevents the grafted skin from firmly affixing to the wound.
Unlike the extremities, splints designed for the neck or the trunk (ie, areas including the shoulder, chest, buttock, axilla, and abdomen) are large and heavy, making them difficult to apply in these locations. Patients using splints on the trunk or the neck feel severe discomfort and, as such, their use is avoided. In these cases, the STSG is covered with a conventional tie-over bolster dressing. However, shearing and/or exudate collection under the graft is not always ensured with a conventional bolster dressing.
Negative pressure wound therapy (NPWT) has been reported to improve wound healing, especially in cases involving wounds located in areas where it is challenging to promote healing due to curvature and movements.[4] Negative pressure dressing is based on the theory of induced mechanical stress resulting in angiogenesis and tissue growth. It also has been suggested that the application of subatmospheric pressure to edematous chronic wounds results in decreased local tissue turgor by fluid removal, which in turn theoretically decompresses small blood vessels, increases blood flow locally, and removes excess interstitial fluid.[5,6] A reduction in bacterial contamination also has been reported.[5,6] The authors conjectured that a negative pressure dressing could help create and maintain firm fixation of the STSGs to a wound on the trunk or the neck as well as allow for the removal of exudates that may accumulate under the grafts.
This study aimed to present our experiences with skin graft fixation using a negative pressure dressing instead of the bolster dressing technique for wounds on the trunk or the neck (Figure 1). Further, this study aimed to compare the efficacy of a negative pressure dressing with the conventional bolster dressing technique of securing STSGs to wounds on the trunk or the neck.
Figure 1.
(A) The negative pressure wound therapy device; and (B) the conventional bolster dressing.